1. The document discusses the anatomy and biomechanics of the foot, including the arches and their supporting structures. 2. It then focuses on flat foot, its types and causes, as well as posterior tibial tendon dysfunction which is a common cause of acquired flat foot in adults. 3. Treatment options for flat foot include conservative measures as well as various surgical procedures depending on the severity and underlying cause, such as arthrodesis and tendon transfers.

1. FLAT FOOT- POSTERIOR
TIBIALIS TENDON
DYSFUNCTION- ACCESSORY
NAVICULARIS
RIZQI D ROSANDI
FK UNIVERSITAS BRAWIJAYA
APRIL 2020
Pengampu : dr. Ananto Satyo Pradana,
Sp. OT

2. ANATOMY OF FOOT

3. • The foot is able to sustain large weight-bearing
stresses while accommodating to a variety of
surfaces and activities.
• The foot must be stable to provide an adequate
base of support and function as a rigid lever for
pushing-off when walking, running, or jumping.
• The foot must also be mobile to adapt to uneven
terrain, absorb shock as the foot hits the ground,

6. ARCHES OF THE FOOT
The arches of the foot, formed by the tarsal
and metatarsal bones, strengthened by
ligaments and tendons, allow the foot to
support the weight of the body in the erect
posture with the least weight.

7. USE OF THE ARCHED FOOT
 Supports body weight in upright posture
 Acts as a lever to propel the body forwards in walking,
running and jumping
 Acts as a shock absorber
 Concavity of the arches protects the soft tissues of the sole
against pressure

8. Medial longitudinal arch
• Higher than lateral
• Composed of – Calcaneous
- Talus
- Navicular
- 3 cuneiform
- 3 metatarsals
• Talar head is key stone of this arch

9. • Tibialis anterior attached to – 1st metatarsal,medial cuneiform –
strength for this arch.
• Peroneus longus tendon – pass laterally to this arch providing
support

10. Lateral longitudinal Arch
• Flatter than medial
longitudinal arch.
• Rests on the ground during
standing.
• It is made up of – calcaneous,
cuboid, 2 lateral metatarsals.

11. Transverse arch
• Runs from side to side
• It is formed by – cuboid,
cuneiforms, bases of
metatarsals
• Medial and lateral parts
of longitudinal arch act as
pillars
• Tendons of fibularis
longus and tibialis
posterior

12. BIOMECHANIC OF FOOT

13. Integrity of bony arches
• Maintained by passive factors and dynamic
supports

14. Passive factors• Shape of the united bones (bony
congruency)
• Four successive layers of fibrous
tissue – bowstring the longitudinal
arch
– Plantar aponeurosis
– Long plantar ligament
– Plantar calcaneocuboid (short
plantar) ligament
– Plantar calcaneonavicular
(spring) ligament

15. Dynamic supports
• Active bracing action of intrinsic muscles of foot
• Active and tonic contraction of muscles with long
tendons extending in to foot
– Flexor hallusis and digitorum longus – longitudinal arch
– Fibularis longus and tibialis posterior – transverse arch
• Plantar ligaments and plantar aponeurosis bear
greatest stress and important in maintaining arches

16. MECHANISM OF ARCH SUPPORT
SHAPE OF BONES
• Bones are wedge-shaped with the thin edge lying inferiorly
• This applies particularly to the bone occupying the center of
the arch“keystone”

17. MECHANISM OF ARCH SUPPORT
Inferior edges of bone tied together

18. MECHANISM OF ARCH SUPPORT
Tying the ends of the arch together

19. MECHANISM OF ARCH SUPPORT
SUSPENDING THE ARCH FROM ABOVE
• Medial longitudinal arch: Tibialis anterior, Tibialis
posterior, medial ligament of ankle joint
• Lateral longitudinal arch: Peroneus longus, Peroneus
brevis
• Transverse arch: Peroneus longus

20. MECHANISM OF ARCH SUPPORT
SUSPENDING THE ARCH FROM ABOVE

21. SO…

22. FLAT FOOT
‘OUR FEET ARE NO MORE ALIKE THAN OUR FACES.’

23. Synonyms
• Pes planovalgus
• Fallen arches
• Pronation of feet

24. Definition
• Absence of normal medial longitudinal arch
• Instep of the foot collapses and comes in
contact with the ground.
• In some individuals, this arch never develops

25. • Flat feet are a common condition.
• In infants and toddlers, the longitudinal arch is not developed
and flat feet are normal.
• The arch develops in childhood
• By adulthood (12-13yrs), most people have developed
normal arches

27. Types
 Flexible
 Rigid
Can be
painless
Painful

28. Types
• Flexible –on weight bearing it disappears and
on non weight bearing it reappears
• Rigid – acceptable medial longitudinal arch
does not seen even on non weight bearing
• Flexible, painless is most common
disappears Appears

29. Etiology
Flexible
Developmental – the most common
Hypermobile (ligamentous hyperlaxity; Ehlers-Donlos, Marfans)
Neurogenic (rare and usually cause the reverse-Pes Cavus)
Rigid
 Congenital (Tarsal coalition,Vertical talus)
Aquired (inflammatory)

30. SYMPTOMS
• Deformity
• Foot pain ,ankle pain, leg pain
• Heel tilts away from the midline of the body more than
usual
• Abnormal shoe wear

32. FLAT FEET CAN produce
• Tendonitis. posterior tibial tendon and it can either fail,
rupture, stretch or just hurt. This condition is called
POSTERIOR TIBIAL DYSFUNCTION (PTD OR TPD) .
• Arthritis.
• Plantar fasciitis
• Bunions & Hammertoes
• Corns and callosities

33. Radiography
• Asymptomatic flatfoot radiological evaluation unnecessary
• First Anteroposterior and lateral views of the foot should
be taken to evaluate severity of deformity
• Antero-posterior ankle to rule out valgus at the distal end of
tibia
• Special view - 45 degree eversion oblique for accessory
navicular bone

34. Radiography
• AP standing view is to asses heel valgus
, talocalcaneal (Kite’s) angle more than
35 degree is associated with incresed
heel valgus
• CT scan accurately defines anatomy
of subtalar joint , allows surgical
planning if it is involved.

35. Meary’s Angle
• Most common angle to indicate
flat foot
• Intersects at apex of the
deformity
• Meary’s angle - between long
axis of talus and long axis of
first metatarsal on a standing
lateral X ray

36.  Normal Meary's angle:long axis
of the talus should bisect the
navicular and first metatarsal
0 degrees – normal
0 – 15 degrees – mild
15 – 40 degrees – moderate
> 40 degrees – severe
The long axis of the talus is angled plantarward in relation to
the first metatarsal, consistent with pes planus

37. Other radiologic signs
Calcaneal Pitch
CYMA Line

38. Pedobarography
 A record of pressure can be obtained
by making the patient to stand and
walk on a force plate.
 Mainly used to compare pre & post
operative function

39. Treatment
0-3 years old:
 No treatment unless very
strong family hx of
persistent flatfeet
 Orthotic shoes with thomas
heels , medial heel wedges
and navicular pads
 Convince the parents.

40. 3-9 years
• Conservative management
• No surgery
• Custom orthosis inserted
with leather ,cork, propylene

41. Exercise
 Toe-walking and multiple toe-ups
 If tendo-achilles is contracted, stretching it actively and passively is an
important form of management
 Grasping marbles with toes Heel to toe walking
 Playing in sand
 Ballet dancing
 Walking on a supination board

43. 10-14 yrs
• No symptom- No treatment
• Symptomatic – conservative management
initially
• Surgical

44. Surgical treatment
Indications
1. Pain
2. Failure to respond to orthotic control
3. Ulceration or callus under the head of the plantiflexed
talus
4. Excessive shoe wear

45. Surgical treatment
• The surgeon , patient, and parents must be willing to
exchange loss of eversion and inversion of the foot
for relief of pain and disability .

46. Surgical treatment
• Arthrodesis for relieving painful flat foot have been
most successful when the subtalar joint is involved .
• Although midtarsal arthtrodesis without inclusion of
the subtalar joint has gained popularity

47. Surgeries
• Durham flatfoot plasty
• Posterior calcaneal displacement osteotomy
• Anterior calcaneal lengthening – distraction
wedge osteotomy
• Triple atrhrodesis (triplane)

48. Durham Plasty for Pes Planus
A, Incision.
B, Elevation of posterior tibial
tendon.
C, Elevation of osteo-periosteal
flap from proximal to distal.
D, Arthrodesis of navicular–first
cuneiform joint.
E, Extent of arthrodesis resection
through midfoot.
F, Internal fixation of navicular–
first cuneiform joint.

49. •
pull the posterior tibial tendon taut
into its prepared bed on the plantar
surface of the waist of the
navicular, and tie the suture
dorsally

50. • Lengthening of lateral
column of the foot by
inserting a tibial bone graft
and calcaneocuboidal
fusion
Calcaneal osteotomy (Dilwyn- Evana, Mosca)

51. • Symptomatic patients with excessive heel valgus , a calcaneal osteotomy
is intended to displace the posterior part of the calcaneum medially , to
restore normal weight bearing alignment
Posterior calcaneal displacement osteotomy (koutsgiannis)

52. Triple Arthrodesis
Joints fused are:
• Subtalar joint
• Calcaneo cuboid joint
• Talo navicular joint

53. AGE
• Usually done after the age of 12
• Triple arthrodesis tend to have a high (50%) failure rate in
children under 10 years of age;
• contra-indicated in young children (less than 10-12 yrs)
because the procedure limits foot growth

54. Complications
• Nonunion
• Degenerative joint disease
• Avascular necrosis
• Lateral instability
• Stiff foot

55. POSTERIOR TIBIALIS TENDON
DYSFUNCTION
THE MOST COMMON CAUSE OF ADULT-ACQUIRED FLATFOOT DEFORMITY

56. Epidemiology
Demographics
 > women
 > present in the 6th decade
Risk Factor
 obesity
 hypertension
 diabetes
 increased age
 corticosteroid use
 seronegative inflammatory disorders

57. Mechanism
 Exact etiology is unknown
 Acute injury vs long standing tendon degeneration

58. Pathoanatomy
Foot deformity
 pes planus
 hindfoot valgus
 forefoot varus
 forefoot abduction
Early Disease Late Disease
• Early tenosynovitis  PPTD
• leads to loss of medial longitudinal
arch dynamic stabilization
• PTTD  attritional failure of static
hindfoot stabilizers & collapse of the
medial longitudinal arch
• Fixed degenerative joint changes occur
at late stages

59. Associated condition
 Inflammatory arthropathy
 tarsal coalition

60. Classification of Tibialis Posterior
Tendon Dysfunction

61. Clinical Presentation
Symptoms
Physical Exam
• Medial ankle/ foot pain &
weakness
• Progressive loss of arch
• Lateral ankle pain
Inspection & Palpation:
• Pes planus
• Hindfoot valgus deformity
• Forefoot abduction
• Tenderness in tip of medial
Range of Motion:
• Single-limb heel rise
• PTT power
• Deformity – flexible or fixed

62. Imaging
 Radiographs :
 Ankle AP/ Lateral
 Ankle Mortise
 MRI :
 Tendon degeneration and arthritic changes in the talonavicular, subtalar,
and tibiotalar joints
 Ultrasound:
• increasing role in the evaluation of pathology within the PTT

63. Differential Diagnostic
 Pes planus, secondary to – midfoor pathology or incompetence of the
spring ligament

64. Treatment
 Nonoperative :
 Ankle foot orthosis
 Immobilization in walking cast (3-4 months)
 Custom molded in shoe orthosis
 Operative :
 Tenosynevectomy
 FDL transfer, calcaneal osteotomy, TAL, +/- forefoot correction osteotomy
+/- spring ligament repair +/- lateral column lengthening +/- medial
column arthrodesis +/- PTT debridement

65. Gatzoulis, 2014: Tibialis posterior dysfunction: a common & treatable cause
of adult acquired flatfoot. BMJ Journal

66. Management of Tibialis Posterior
Tendon Dysfunction
Abousayed et al.,
2017: JBJS Journal

67. Treatment
 First TMT joint arthrodesis, calcaneal osteotomy, TAL +/- lateral column
lengthening +/- PTT debridement
 Isolated subtalar arthrodesis
 Hindfoot arthrodesis
 Triple arthrodesis & TAL+ deltoid ligament reconstruction
 Tibiotalocalcaneal arthrodesis

68. ACCESORY NAVICULAR
FIRST DESCRIBED BY BAUHIN IN 1605
OTHER NAMES : PREHALLUX, ACCESSORY SCAPHOID, NAVICULAR SECUNDUM

69. Accessory navicular bone
• It is a most common accessory bone in the foot
• Listed as a cause of flat foot

70. Pathoanatomy
• Abnormal insertion of Tibialis Posterior into
accessory navicular bone believe to cause the flat
foot

71. Clinical presentation
• Often incidental, many patients are asymptomatic
• Pain
• Prominence of medial aspect of foot
• On attempted inversion of the foot against resistance
, Tibialis posterior tendon is inserted into the bump
and this maneuver produces pain

72. Radiography
• Special view - 45 degree eversion oblique for
accessory navicular bone
• Antero-Posterior view and Lateral weight bearing
views of the foot should be taken to evaluate other
deformities

74. Radiological types
• TypeI– Small ossicle in the substance of Tibialis
Posterior tendon (os tibiale externum or naviculam
secondorium )
• Type II –Triangular frangment larger than type I connected
to navicular bone by a cartilaginous synchondrosis
• Type III – Cornuate navicular resulting from fusion of the
accessory navicular with main body of navicular

76. Treatment
INITIAL TREATMENT:
Conservative- stretcing shoes, avoiding activity
that irritates foot
SURGICAL:
Kidners procedure

77. Kidners procedure• Excision of accessory
navicular bone and rerouting
of tibialis Posterior tendon
into a more plantar position
(navicular)
• Parents should be informed
before surgery that pain
may not be alleviated
completely

78. THANK YOU
MALANG, 16 APRIL 2020